Nursing Content Standards

Anne Casey FRCNEditor Paediatric Nursing

Adviser in Informatics Standards, RCN

Clinical Lead, NHS (England) Information Standards Board

Member, SNOMED Content Committee

Nursing Content Standards?

These are the standards that a regulator (the NMC) would expect a registered nurse to conform to related to the content of a patient record or communication from it i.e.– The Professional / regulatory specification for the

detail of what should be recorded about the nursing management of the patient, including content of communications

Can we learn from the RCP? Record programme – to April 08

Generic standards for medical (hospital) records

Content of: – Acute medical admission ‘clerking’ – Discharge from hospital record (medical)– Doctor’s component of handover record

‘Record once, use many times’

Not necessarily a ‘one to one’ match between clinical content item and secondary uses data item

Unless we get the content piece defined and into electronic record systems, nurses will still be expected to record for activity / costing analysis. For example:– The pick list of community nursing intervention terms will be

at a higher level of abstraction than is needed for care: ‘daily wound dressing’ rather than ‘dress ulcer on right leg using xxx cream and yyy dressing’.

Two tasks for the profession1. Define record content standards for safe and good

quality care e.g. every adult patient admitted to hospital should have a falls risk assessment using xx validated assessment tool and the result should be recorded. This step provides the system developer with a professionally

defined system requirement.

2. Define (separately) the data requirements to support specific secondary analyses such as audit of falls risk assessment outcomes etc. If we don’t complete the first task we are in danger of having the

secondary requirements continuing to drive what nurses are expected to record.

Standard nursing terminology?  The NHS standard, multidisciplinary

terminology for use in electronic records is SNOMED Clinical Terms (CT)

Terms from existing nursing terminologies are present in SNOMED CT

Existing nursing terminologies/classifications may be fit for purpose of recording / extracting data but until the requirements (see previous slide) are clear we cannot make that judgement.

What do we need (RCN)?

Process and infrastructure for appraising and endorsing content standards – RLI team are discussing

Generic process for developing, testing and maintaining content standards– RLI team are discussing

Projects to develop priority content standards– Much could be done by forums a la competency

development but with better support Capacity to participate in collaborative work

– ????